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time basedcoding

Amy Posted Mon 25th of November, 2019 01:44:56 AM
provider spends 40 minutes spent with face-to-face communication, patient education, care coordination, and documentation. without more than 50% can we consider this time to code 99233 in hospital progress note. how you consider this time on outpatient setting?
SuperCoder Answered Tue 26th of November, 2019 03:05:49 AM



No, you cannot code based on time with just the documentation you have mentioned.

You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care.

CPT states in its E/M guidelines that "When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record."


It is appropriate to make E/M level on the basis of 3 components i.e. history, examination and medical decision-making.


Please also check below link for better understanding:



Amy Posted Wed 27th of November, 2019 00:59:53 AM
thank you
SuperCoder Answered Wed 27th of November, 2019 23:04:23 PM

Thank you, happy to help.

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